Briarcrest Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bell Gardens, California.
- Location
- 5648 East Gotham Street, Bell Gardens, California 90201
- CMS Provider Number
- 056220
- Inspections on file
- 77
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Briarcrest Nursing Center during CMS and state inspections, most recent first.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple psychiatric and orthopedic diagnoses alleged that a CNA hit her during a shower. An RN reported performing a full body assessment and identifying a bluish discoloration on the resident’s hip, but this assessment was not documented in the medical record and was instead placed only in an abuse investigation file. The Change of Condition documentation noted notification of the PCP about the abuse allegation but did not reflect a head-to-toe assessment, did not record the discoloration, and did not show that the PCP was informed of the bruise. The RN was unable to reach the PCP and did not escalate to the Medical Director, contrary to facility P&P requiring injury assessment, documentation, and physician notification after incidents and abuse allegations.
A resident with respiratory failure, hypoxia, and dependence in multiple ADLs was transferred to a GACH for G-tube replacement, but the facility did not provide the required written Bed-Hold notice to the resident’s responsible party at the time of transfer. The Business Office Manager indicated nursing was responsible for issuing Bed-Hold notices, while the DON reported that staff only verbally informed responsible parties and was unaware of the written notice requirement. Review of the facility’s Bed-Holds and Returns P&P showed that residents or representatives must receive written bed-hold information twice, including at the time of transfer, but this second written notice was not provided.
A resident with dementia, depression, anxiety, and a recent femur fracture alleged being hit during a shower, prompting an RN to perform a head-to-toe assessment and identify a bruise on the hip. The RN documented this finding only on a separate paper form used for an abuse investigation, not in the medical record or on the Change of Condition (COC) form. The COC instead recorded that the PCP was notified and included a PCP recommendation to monitor for pain and sadness, even though the RN later stated the PCP had not been reached and that this recommendation was incorrect. The COC also omitted any reference to the full body assessment or the bruise, contrary to facility policy requiring complete, accurate, and objective documentation of assessment findings and physician notification.
A resident with bipolar disorder, COPD, and HTN was prescribed quetiapine for aggressive angry outbursts, with the care plan and orders requiring every-shift monitoring and documentation of target behaviors. For an extended period after the antipsychotic was initiated, nursing staff did not perform or document the required behavior monitoring, despite facility policies mandating observation and reporting of specific behaviors and medication efficacy. RN and DON interviews confirmed that this monitoring was necessary for the physician to evaluate treatment effectiveness and consider dose adjustments or GDR, but it was not carried out as ordered.
Two roommates became involved in a verbal altercation over cigarettes and a cell phone that one resident had entrusted to the other while away at a GACH. Nursing staff de-escalated the initial argument and left both residents in the same room, despite a facility policy requiring separation of residents after an altercation. The residents remained together overnight, and the conflict resumed the next morning, when one resident pushed the other into a nightstand, causing a documented eyebrow abrasion. Multiple staff, including an RN, LVNs, the SSD, the DON, and the Administrator, later acknowledged that the residents were not separated after the first altercation as required by policy, and that a room change should have been implemented.
A resident with bipolar disorder, COPD, and HTN, receiving quetiapine for aggressive outbursts and identified on PASRR Level 1 as having a serious mental illness, was admitted under a physician-certified 30-day exempted hospital discharge. Although the resident’s stay extended beyond 30 days, the facility did not submit the required PASRR Resident Review Level 1, despite a Level 2 letter and state guidance specifying that a new Level 1 must be completed if the stay exceeds 30 days. The MDS nurse and DON acknowledged that the resident remained in the facility past 30 days and that the facility was responsible for resubmitting the Level 1 screening in accordance with facility policy and DHCS PASRR requirements.
A resident with dementia, generalized muscle weakness, and chronic atrial fibrillation, who was severely cognitively impaired and dependent on staff for several ADLs, was observed in bed with bilateral grab bars used for mobility and repositioning. Review of records showed no MD orders for grab bars and no person-centered care plan addressing the use of side rails or related safety interventions over an extended period. An RN and the DON both acknowledged that a care plan should have been in place to describe the reason for the grab bars and to direct staff monitoring of the resident’s use, positioning, and the condition of the equipment, in accordance with the facility’s comprehensive care plan policy.
Surveyors found that staff installed bilateral bed grab bars for two residents with impaired cognition and significant physical limitations without completing accurate side rail utilization assessments, obtaining physician orders, or documenting informed consent. In both cases, the medical record assessments indicated no side rails in use or requested, yet grab bars were observed on the beds and used for mobility and repositioning. Review of active orders and the eHR showed no orders or consent documentation, despite facility policy and the DON’s statements that an order, assessment, and informed consent were required before bed rail use.
A resident with intact cognition and decision-making capacity, who had multiple chronic conditions, requested that staff stop informing a previously designated family emergency contact about his care to avoid causing her worry. This request was documented by an RN, yet another nurse later notified the same family member of a change in the resident’s condition involving respiratory symptoms. The resident reported feeling frustrated and distrustful, and both the RN and DON acknowledged that the resident’s right to privacy and autonomy was not honored and that the emergency contact information was not updated to reflect his wishes, contrary to facility policies on resident rights and confidentiality.
A resident with severe cognitive impairment, total dependence for ADLs, high Braden risk, and a Stage 4 trochanteric PI was ordered to use a P.R.O. Plus LALM for wound management. Facility education and staff statements indicated that only a thin sheet and a disposable pad should be used on the LALM to maintain its pressure redistribution function. However, surveyors observed multiple layers between the resident and the mattress, including extra sheets and a pad used to facilitate repositioning and prevent sliding. Staff acknowledged this was contrary to the LALM guidelines, and the DON and treatment nurse confirmed that excess linen layers interfered with the mattress’s intended pressure-relieving effect, resulting in a deficiency for failure to follow LALM linen-use protocols.
A resident with hemiplegia, hemiparesis, aphasia, severe cognitive impairment, and documented fall risk was care planned and ordered to have bilateral half side rails and two-person assistance for bed mobility and repositioning. Despite this, a CNA provided incontinence care and repositioned the resident onto her side alone, without checking the Kardex and without side rails in place, contrary to the care plan and facility policy. During this one-person repositioning, the resident shifted, slid, and rolled off the bed to the floor, demonstrating the facility’s failure to implement ordered safety devices and required staffing support during repositioning.
A resident with severe cognitive impairment and total dependence on staff alleged to his responsible party that he was hit by an unidentified male CNA. The DON and Administrator were made aware of the allegation but did not report it to the State Agency within the required timeframe, despite facility policy and federal requirements mandating prompt reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence on staff for care alleged being hit by an unidentified male CNA, as reported by the responsible party. Despite facility policy and federal requirements mandating investigation of all abuse allegations, both the DON and Administrator acknowledged that no investigation was conducted into the reported incident.
A resident with severe cognitive impairment and multiple complex medical needs did not receive neurological assessments at the required frequency after an alleged head injury by a CNA. The RN responsible failed to perform neuro-checks at the scheduled intervals, with some checks delayed and others clustered together, contrary to facility policy and physician orders. The DON confirmed the assessments were not completed as required.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, resulting in a deficiency related to privacy and documentation requirements.
A resident with dementia, epilepsy, and anxiety disorder, who required maximal assistance with ADLs and had fluctuating mental capacity, did not have an individualized care plan developed to address dementia. Nursing staff confirmed the absence of a care plan, despite facility policy requiring comprehensive, person-centered plans with measurable objectives.
A resident with a history of heart failure and kidney disease was admitted with physician orders for fluid restriction and use of a condom catheter for I&O monitoring. Despite documented changes in the resident's condition, including worsening edema and respiratory distress, staff interviews and record reviews confirmed that no comprehensive, resident-centered care plan was developed or updated to address these needs, in violation of facility policy.
A resident with a documented seafood allergy and multiple dietary restrictions was served pureed fish after staff failed to properly identify the allergy on the tray card and did not adequately verify the meal before service. The resident consumed the fish, experienced an allergic reaction, and required medication. Staff interviews revealed that the allergy was not clearly marked on the tray card and that required double-checks of meal trays were not performed.
Staff failed to wear required PPE and ensure proper signage while providing wound care to two residents on Enhanced Barrier Precautions (EBP). An LVN and a restorative nursing assistant performed dressing changes without isolation gowns, despite physician orders and facility policy mandating PPE use for residents with open wounds and MDRO risk. Both residents had significant cognitive and physical impairments and required extensive assistance with daily living.
A resident with multiple chronic conditions was left with a cup of medications at her bedside by an LVN, without supervision or an IDT assessment for self-administration. The resident had not been evaluated for her ability to self-administer medications, and there was no physician order permitting this practice. Facility staff confirmed that medications should not be left unattended and that an IDT assessment is required before allowing self-administration, as outlined in facility policy.
A resident with a history of chronic respiratory failure and tracheostomy dependence experienced sustained tachycardia and tachypnea, but nursing staff did not promptly assess or notify the physician as required by facility policy. Despite documentation of abnormal vital signs for several hours, the physician was not contacted until later in the day, resulting in delayed treatment and transfer to an acute care hospital.
Two residents experienced deficiencies in accident prevention and supervision. One resident, dependent on staff for bed mobility and toileting, was repositioned by a CNA without required two-person assistance, resulting in a fall and bilateral femur fractures requiring surgery and transfusion. Another resident, at high risk for falls, did not have a call light within reach or fall mats in place as specified in the care plan, increasing the risk of injury. Facility policies and care plans requiring these safety measures were not followed.
The facility did not ensure that an MDS nurse demonstrated required competencies or received annual evaluations of her ability to accurately perform MDS assessments. Despite access to the RAI manual and periodic audits of completed assessments, there was no direct observation or formal evaluation of the nurse's performance, as required by facility policy. This failure placed all residents at risk of inaccurate MDS assessments and care planning.
The facility did not implement required infection control measures for several residents, including failing to post EBP signage for two residents with indwelling devices, not changing respiratory equipment as per policy for two residents, and leaving suction equipment on the floor for another resident. These actions were confirmed through observations, record reviews, and staff interviews, and were not in accordance with facility policies.
A resident with severe cognitive impairment was admitted with a personal blanket, which was laundered by staff but not labeled or returned. The blanket was later found in storage, and the lack of labeling led to staff being unaware of its ownership, resulting in the resident not maintaining possession of her belonging.
Two residents with significant physical and cognitive impairments were unable to access their call lights due to improper placement, and one resident did not receive needed assistance to wear her prescribed bifocal glasses. Staff interviews confirmed awareness of the residents' limitations and the importance of individualized call light placement and support with adaptive devices, but these needs were not consistently met.
Four residents did not receive accurate MDS assessments, with errors including failure to document vision needs, extremity impairments, dental status, and accurate levels of dependence for ADLs. MDS nurses did not follow RAI manual protocols or facility policy, leading to assessments that did not reflect residents' actual conditions as documented in medical records, therapy notes, and CNA documentation.
A resident with multiple mental health diagnoses was identified as needing a Level II PASRR evaluation to determine eligibility for specialized mental health services, but the evaluation was not completed or followed up on. Facility staff, including the SSD and MDS nurse, were unfamiliar with the PASRR process and responsibilities, and there was no policy or procedure in place to ensure required PASRR evaluations were conducted.
Several residents did not have care plans developed or implemented for critical needs, including fall prevention, insulin administration, seizure and anticoagulant medications, use of corrective lenses, dental status, and safety devices. Staff interviews and record reviews confirmed that these omissions left staff without guidance on required interventions and monitoring, resulting in unmet resident needs.
Two residents with severe cognitive impairment and ADL deficits were found with long, dirty fingernails and toenails, despite care plans and facility policy requiring daily cleaning and trimming. Staff confirmed that nail care was their responsibility and acknowledged the deficiency in providing necessary hygiene assistance.
A resident with severe cognitive impairment, morbid obesity, and high risk for pressure ulcers was found lying on a low air loss mattress that was set above their actual weight, contrary to facility policy and manufacturer guidelines. Nursing staff confirmed the incorrect setting, which resulted in the resident being on a harder surface not suitable for their skin integrity needs.
A resident with significant neurological impairments developed a right-hand contracture, but the required notification to the DOR or LVN was not completed. The restorative nurse aide observed the change but did not document it on the Stop and Watch form, and the DOR was not made aware, delaying potential interventions such as hand splinting. Facility policy required immediate reporting of such changes, which was not followed.
Two residents receiving IV antibiotics did not have their midline catheter sites assessed every shift or their dressings changed every seven days as required by facility policy. One resident's dressing was overdue for change, and another's was soiled and dislocated, with both cases lacking proper documentation and assessment by nursing staff.
A resident with severe physical and cognitive impairments was not repositioned at least every two hours as required, resulting in unmanaged pain. The resident's call light was also not placed within effective reach, preventing her from requesting assistance. Staff and policy reviews confirmed these failures, which led to the resident experiencing prolonged pain and inability to communicate her needs.
A resident with dementia and behavioral symptoms was prescribed a new antipsychotic after hospital readmission, but staff did not properly document physician awareness of the new medication. When the resident later exhibited aggressive behaviors, a psychiatric consult was ordered but not initiated due to staff oversight, resulting in a delay of necessary behavioral health services.
A resident's room was found to have a window screen with large gaps that allowed insects to enter, and a broken, unsecured toilet seat that created a safety concern. The maintenance manager confirmed both issues and acknowledged responsibility for maintaining safe equipment, while facility policy required regular safety inspections and proper maintenance.
A resident with cognitive impairment and a history of wandering activated an exit door alarm, but staff failed to report the incident, increase supervision, or monitor exit doors as required. The resident was not educated on elopement risks and was able to leave the facility unsupervised through a back exit door with a non-functioning alarm.
The facility did not adhere to infection control practices by failing to follow posted Novel Respiratory Precautions for COVID-19 isolation rooms. Staff, including an LVN and an RNA, entered isolation rooms without wearing required PPE such as gowns and face shields, despite signs indicating the need for full protective gear. Interviews confirmed that staff were aware of the PPE requirements but did not consistently comply, risking the spread of infection.
A resident with multiple medical conditions was found with unexplained bruising and skin discolorations. The facility failed to report these injuries of unknown source to the State Agency within the required timeframe, attributing them to the resident's condition instead. This delay in reporting hindered the investigation and placed the resident at risk for continuous abuse.
A resident with multiple medical conditions developed unexplained skin discolorations and bruising, which the facility failed to investigate as required by their policies. Despite the resident's inability to communicate and total dependence on staff, the injuries were attributed to medical history without a thorough investigation, leaving potential abuse unaddressed.
A resident with total bladder incontinence developed Moisture-Associated Skin Damage (MASD) due to the facility's failure to implement the care plan. The resident was not checked frequently enough for incontinence, leading to MASD in the sacrococcyx and bilateral groin areas. Staff interviews confirmed that the condition was preventable and resulted from inadequate care.
A facility failed to ensure safe gastric tube feeding for a resident, as a CNA lowered the head of the bed while the feeding pump was running, contrary to physician orders. The CNA paused the pump, although CNAs are not authorized to operate it. The LVN and DON confirmed that CNAs should notify a licensed nurse to manage the pump, as per facility policy.
A resident with quadriplegia fell and sustained a cervical fracture when a CNA attempted a solo transfer using a Hoyer Lift, despite the requirement for a two-person assist. The CNA admitted to rushing and not seeking help, leading to the lift tipping over. Facility policies and the lift's manual both mandated a two-person assist for safe transfers.
A resident with quadriplegia was injured during a transfer when a CNA failed to follow the care plan requiring a two-person assist with a Hoyer Lift. The CNA attempted the transfer alone, resulting in the lift tipping over and causing a fracture in the resident's C5 vertebra. The resident experienced severe pain and required hospitalization. The CNA was aware of the two-person assist requirement but proceeded alone due to time constraints, leading to the incident being classified as neglect.
A resident with severe cognitive impairment and swallowing difficulties was not provided with the correct minced and moist diet as ordered by the physician. Instead, the resident was served inappropriate food items, including full-size pasta and a regular bread roll, which did not meet the required consistency. Facility staff interviews revealed a failure to adhere to policies ensuring the correct diet was served, posing a risk of choking and other complications.
A facility failed to obtain informed consent before increasing a resident's lorazepam dosage, violating their right to make informed decisions. Despite the resident's capacity to understand and make decisions, the increased dosage was administered without consent. Staff interviews confirmed the oversight, acknowledging the necessity of informed consent for dosage changes, as outlined in the facility's policies.
A resident with anxiety disorder and depression had a care plan that was not updated to reflect a physician's order for Lorazepam 1 mg every 12 hours, instead showing 0.5 mg. Interviews with nursing staff confirmed the care plan should have been revised to ensure accurate medication administration, as per facility policy.
The facility failed to respond to call lights promptly for three residents, impacting their care and well-being. A resident with fractures experienced daily delays, while another with respiratory failure felt neglected and mistreated by staff. A third resident, dependent on assistance, faced long waits for diaper changes. Staff interviews confirmed that the facility's policy of answering call lights within five minutes was not consistently followed.
A resident with respiratory failure and chronic pulmonary edema did not receive safe oxygen administration as per physician's orders. The oxygen was set at 3 LPM instead of the prescribed 2 LPM, and the nasal cannula tubing was not labeled or replaced after touching the floor. Staff interviews revealed a lack of knowledge about the facility's oxygen administration policy and the resident's specific orders.
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Notify Physician and Document Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for change in condition and abuse/neglect clinical protocol for one resident. The resident, who had dementia, major depressive disorder, anxiety disorder, and a history of right femur fracture, was assessed as having severe cognitive impairment and being dependent for ADLs including toileting, bathing, and bed mobility. On 3/14/2026, the resident reported an allegation of abuse, stating that during a shower a CNA hit her on the head. A Change of Condition (COC) form dated 3/14/2026 showed that the primary care physician (PCP) was notified of the allegation that day at 4:24 p.m., but the COC did not document that a full head-to-toe assessment was completed, did not record any discoloration or bruising, and did not indicate that the PCP was notified of any such findings. In interviews, RN 1 stated that he did perform a full body assessment after the allegation and found a finger-length bluish discoloration on the resident’s left hip on 3/14/2026. However, this skin assessment was not entered into the resident’s medical record and was instead documented on a separate paper form kept in the abuse investigation file. RN 1 also stated he was unable to reach the resident’s PCP regarding both the allegation of abuse and the skin discoloration and did not notify the Medical Director. The DON confirmed that a head-to-toe skin assessment should be completed and documented for all abuse allegations, that any skin discolorations should be reported to the PCP, and that staff should contact the Medical Director if the PCP cannot be reached. Facility policies titled “Change in a Resident’s Condition or Status” and “Abuse and Neglect – Clinical Protocol” required the nurse to assess the resident, document injury assessment findings, and report those findings to the physician after an accident, incident, or allegation of abuse, which was not fully done in this case.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0580 Notify of Changes (Injury/Decline/Room, etc.) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was immediately reassessed on 03/26/2026 by the Director of Nursing (DON) and licensed nurse. A comprehensive head-to-toe assessment was completed and documented in the medical record. The attending physician (PCP) were notified on 03/26/2026 of the allegation, identified bruise, and current condition. Physician orders were reviewed and implemented as indicated. The resident representative was notified on 03/26/2026. The interdisciplinary team (IDT) reviewed the incident to ensure psychosocial needs were addressed, including monitoring for behavioral changes related to the allegation. The facility corrected the documentation deficiency by ensuring the skin assessment findings were entered into the electronic medical record (EMR) and cross-referenced to the abuse investigation. Staff involved (RN-1) received immediate re-education by the Director of Nursing (DON) on 03/26/2026 regarding timely physician notification, documentation standards, and escalation protocol when the PCP is unavailable. No adverse outcome to the resident was identified. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 03/28/2026, the Director of Nursing (DON) and/or designee conducted a 12-day look-back audit covering the period of 03/14/2026 through 03/26/2026 for residents who experienced a change of condition, incident, injury, or allegation of abuse. The audit included a review of Change of Condition (COC) documentation, incident/accident reports, and nursing progress notes to verify timely physician notification, completion of head-to-toe-toe assessments, and accurate documentation in the electronic medical record (EMR). No other residents were identified and affected by the deficiency. Licensed staff involved received targeted re-education on notification requirements and escalation protocols by the Director of Staff Developer (DSD). What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: Briarcrest Nursing Center reinforced notification of changes to ensure compliance with physician notification and documentation requirements. A standardized escalation protocol was enforced requiring nursing staff to notify the Medical Director or physician on-call if the attending physician is not reached within one hour, with all attempts documented in the EMR and requiring completion of A head-to-toe assessment, injury documentation, and physician notification details prior to finalizing the entry. The facility reinforced its Abuse and Neglect Clinical Protocol to require that all assessment findings be documented in the EMR. Licensed nursing staff were provided mandatory re-education by Director of Staff and Development (DSD) on 03/27/2026 regarding facility policies, and escalation requirements. The DON and/or designee conducts a 24-hour review of all incidents and COC reports at the clinical start-up and stand down to ensure compliance and immediate correction of any deficiencies. How the facility plans to monitor its performance to make sure that solutions are sustained: To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The Medical records supervisor initiated weekly audits for four weeks beginning 03/26/2026, reviewing a change of condition or incident to ensure timely physician notification, proper escalation, and complete documentation. This is followed by monthly audits for three months. Audit findings are reported to the QAPI Committee monthly with corrective actions implemented as needed. If no negative trends are identified after three consecutive months, the monitoring will be discontinued and removed from active QAPI tracking. If trends are identified, the facility will revise and continue the monitoring plan. Dates when corrective action will be completed: 4/17/2026
Failure to Provide Required Written Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required written Bed-Hold notice to a resident’s responsible party (RP) at the time of the resident’s transfer to a general acute care hospital (GACH). The resident, who had diagnoses including respiratory failure with hypoxia, was originally admitted and later readmitted to the facility, and an H&P dated 2/21/2026 documented that the resident did not have the capacity to understand and make decisions. An MDS dated 3/10/2026 showed the resident was dependent for ADLs such as toileting hygiene, showering/bathing, and bed mobility. The resident was transferred to the GACH for a G-tube replacement, and the discharge summary documented this transfer. Review of the resident’s Bed-hold Informed Consent/Notification Form dated 2/21/2026 showed no indication that a Notice of Bed-hold was provided to the RP after the transfer on 3/10/2026. During interviews, the Business Office Manager stated that the nursing department was responsible for providing the Bed-Hold Notice to residents or their RPs. In a concurrent interview and record review, the DON stated that residents’ beds should be held for seven days when they are transferred to the GACH and that staff would verbally inform RPs about the bed-hold at the time of transfer. The DON also stated she was not aware that written notices should be provided to RPs and acknowledged that, according to the facility’s undated P&P titled “Bed-Holds and Returns,” a written second notice should have been provided to the RP at the time of transfer and that the facility did not follow this P&P. The P&P specified that all residents or representatives are to be provided written information about bed-hold policies at least twice: once in advance of any transfer (e.g., in the admission packet) and a second time at the time of transfer or within 24 hours if the transfer is an emergency.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0628 Discharge Process How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately reviewed on 03/27/2026 following identification of the deficient practice. The facility verified that the resident was readmitted on 03/25/2026 without loss of bed or services. On 03/25/2026, the party responsible was contacted by the Director of Nursing (DON) and provided re-education regarding the facility's bed-hold policy, including the 7-day bed-hold provision. A written Bed-Hold Notice was issued retroactively and explained to the party responsible, with documentation placed in the medical record. The interdisciplinary team reviewed the discharge and transfer documentation to ensure all required elements were completed. No adverse outcome occurred. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents transferred to the hospital or on therapeutic leave. The audit focused on compliance with written Bed-Hold Notice requirements at the time of transfer. A total of applicable transfer records was reviewed by the DON and Medical Records Supervisor. No additional residents were identified as missing, written Bed-Hold Notices at the time of transfer. All licensed nurses, unit managers, and admissions staff were re-educated on 03/27/2026 by the Development of Staff Development (DSD) on requirements for discharge documentation and bed-hold notification. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility will reinforce the systemic corrective actions on discharge process to ensure compliance with the requirements for discharge and bed-hold notification. A standardized Bed-Hold Notice process was incorporated into the transfer workflow, requiring completion of a written notice at the time of transfer or within 24 hours for emergency transfers. The Electronic Medical Record (EMR) was re-enforced to include a required field for Bed-Hold Notice documentation. Licensed nurses, admissions staff, and business office personnel were re-educated on 03/27/2026, by DSD to ensure understanding of regulatory requirements and facility expectations. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility will monitor compliance through a structured audit process integrated into the Quality Assurance and Performance Improvement (QAPI) program. Weekly audits of randomly selected residents who experienced hospital transfers will be conducted for four consecutive weeks by Medical Records Supervisor from 03/28/2026 through 04/25/2026, followed by monthly audits for three months from May through July 2026. Audits will evaluate the presence, timeliness, and completeness of written Bed-Hold Notices, including documentation in the EMR and notification of the responsible party. Audit results will be reviewed by the Director of Nursing and/or designee and reported to the QAPI Committee monthly. Any identified non-compliance will result in immediate corrective action, including documentation correction, staff re-education, and progressive discipline if indicated. After three months, the QAPI Committee will evaluate audit findings for trends; if no trends are identified, the monitoring process will be discontinued, and if trends persist, corrective actions and monitoring will be extended to ensure sustained compliance. Dates when corrective action will be completed. 4/17/2026
Incomplete and Inaccurate Documentation After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for one resident following an allegation of abuse. The resident, who had diagnoses including a right femur fracture, dementia, major depressive disorder, and anxiety disorder, and who was assessed as having severe cognitive impairment and dependence for ADLs, reported on 3/14/2026 that a CNA hit her on the head during a shower. RN 1 stated he performed a full body assessment at that time and identified a finger-length bluish discoloration/bruise on the resident’s left hip. However, this full body assessment and the bruise were not documented in the resident’s medical record or on the Change of Condition (COC) form; instead, the skin assessment was recorded on a separate paper form kept in the abuse investigation file. The COC form dated 3/14/2026 documented that the resident’s PCP was notified at 4:24 p.m. and included a PCP recommendation to monitor for pain and episodes of sadness/depression for 72 hours, but the form did not indicate that a full body assessment was completed or that any discoloration/bruise was present. In a later interview, RN 1 stated he had been unable to reach the PCP on that date and acknowledged that the PCP recommendation documented on the COC was incorrect and should not have been entered. The DON confirmed that if staff did not reach the PCP, the recommendation section should have been left blank and attempts to contact the PCP documented in progress notes, and also confirmed that the COC lacked documentation of the bruise found during the assessment. The facility’s policy on charting and documentation required that medical record documentation be objective, complete, and accurate, and that procedures and treatments include assessment data and unusual findings, as well as notification of the physician when indicated.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0842 Resident Records - Identifiable Information How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:Resident 2's medical record was immediately corrected on 03/27/2026 to reflect a complete and accurate clinical picture. A late entry was entered by the Licensed Nurse documenting the full body assessment completed on 03/14/2026, including the identified bruise/discoloration to the left hip. The Change in Condition (COC) documentation was corrected to remove the inaccurate "PCP recommendation," and a clarification note was entered indicating that the physician was not reached at the time of the incident. The attending physician was notified on 03/26/2026, and appropriate clinical follow-up was completed. Staff involved (RN 1) received immediate re-education by the Director of Nursing on 3/26/2026 regarding accurate, complete, and non-speculative documentation per facility policy "Charting and Documentation". No adverse outcome to the resident was identified. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents with documented Change in Condition (COC), skin assessments, or incident reports. The audit focused on completeness of documentation, and validation of physician communication. No additional residents were found to have inaccurate physician recommendations documented without verification. Licensed nurses were re-educated on requirements by the Director of Staff Developer (DSD) on 3/27/2026 emphasizing that all clinical findings must be documented in the medical record. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur.The facility reinforced the standardized EMR documentation review for Change in Condition (COC) events requiring completion of a full body assessment, inclusion of all skin findings, and verification of physician communication prior to documenting any recommendations.The abuse investigation workflow was reenforced to ensure that clinical findings are integrated into the medical record to support continuity of care and regulatory compliance. Licensed nurses were re-educated by the DSD ON 03/27/2026 on documentation standards, including accuracy, completeness, and prohibition of speculative entries, as well as confidentiality requirements. These system changes were implemented to ensure medical records remain complete, accurate, and readily accessible, and to prevent recurrence of the deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained.To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program.The facility will reinforce the structured monitoring system to ensure sustained compliance. A weekly audit by the Medical Records Supervisor of randomly selected residents with Change in Condition documentation will be conducted for four consecutive weeks focusing on completeness, accuracy, and verified physician communication. Following this period, audits will be conducted monthly for three months. Audit results will be reviewed by the Director of Nursing and reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Any identified discrepancies will result in immediate corrective action, including re-education and documentation correction. If no trends or repeat deficiencies are identified after three months, the issue will be considered resolved and removed from active QAPI monitoring. If trends are identified, the audit frequency will be increased and additional interventions implemented. The facility will evaluate the effectiveness of corrective actions through ongoing compliance rates. Dates when corrective action will be completed. 4/17/2026
Failure to Monitor Behaviors for Resident on Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document behavioral symptoms for a resident receiving an antipsychotic medication. The resident had diagnoses including bipolar disorder, COPD, and hypertension, with an MDS showing moderately impaired cognitive skills and a need for moderate assistance with several ADLs. The resident was prescribed quetiapine 100 mg at bedtime for bipolar disorder manifested by aggressive angry outbursts, and the care plan directed staff to monitor and record occurrences of these target behavior symptoms. The initial psychiatric evaluation indicated that medications were to be titrated according to the resident’s symptoms. Record review and staff interviews showed that although the resident had been treated with quetiapine since mid-November, behavior monitoring every shift for aggressive angry outbursts did not begin until January 20. RN 1 confirmed that from the start of quetiapine therapy through January 19, the resident was not monitored every shift for aggressive angry outbursts, despite orders and care plan requirements to do so. RN 1 and the DON both stated that licensed nurses were responsible for monitoring and documenting the number of behavior occurrences each shift so that the physician could evaluate the effectiveness of the antipsychotic, identify trends, and consider dose adjustments or GDR. Facility policies on antipsychotic medication use and behavioral assessment required staff to observe, document, and report information on target behaviors and medication efficacy, which was not done for this resident during the identified period.
Failure to Separate Roommates After Verbal Altercation Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure titled “Resident-to-Resident Altercations,” which required staff to separate residents involved in an altercation. Two residents, identified as Residents 4 and 5, were roommates and became involved in a verbal altercation on the evening of 1/9/2026 related to personal belongings, specifically cigarettes and a cell phone that Resident 4 had entrusted to Resident 5 while he was at a general acute care hospital. Licensed vocational nurses (LVN 2 and LVN 3) intervened to de-escalate the situation by returning the phone and providing a cigarette, and both residents appeared calm and were left in the same room to sleep. RN 4 was informed of the verbal altercation by LVN 2 and LVN 3 and, upon checking the room and finding both residents sleeping, did not wake them and instead verbally relayed that one of the residents should be moved once they awoke. No room change or separation was implemented at that time. Resident 4 had a history that included bipolar disorder, COPD, and hypertension, with a Minimum Data Set (MDS) indicating moderately impaired cognitive skills for daily decision-making and use of antipsychotic medication. His History and Physical documented that he had capacity to understand and make decisions. Resident 5’s diagnoses included osteomyelitis of the right ankle and foot, type 2 diabetes mellitus, and acute kidney failure, with an MDS indicating intact cognition and a need for moderate assistance with certain activities of daily living. Despite the facility’s policy requiring separation of residents after an altercation, both residents remained in the same room overnight following the initial verbal conflict. On the morning of 1/10/2026, a second altercation occurred between the same two residents, again related to the cigarettes that Resident 4 had entrusted to Resident 5. Resident 4 reported that upon readmission from the hospital he discovered that Resident 5 had smoked all of his cigarettes, leading to anger, yelling, and derogatory name-calling. CNA 1 heard yelling from the room, entered, and witnessed Resident 5 stand up and push Resident 4 against the nightstand. CNA 1 called for assistance and separated the residents, then informed RN 3. RN 3 observed that the physical altercation had ended and noted an abrasion above Resident 4’s right eyebrow. Documentation in the Change in Condition note and Skin Assessment on 1/10/2026 confirmed that Resident 4 sustained an abrasion measuring 1.5 cm by 1 cm above his right eyebrow as a result of being pushed into the nightstand. During interviews, RN 2, the Social Services Director, the Director of Nursing, and the Administrator all acknowledged that the residents were not separated after the initial verbal altercation and that a room change should have been considered or conducted, consistent with the facility’s policy, to prevent further altercations.
Failure to Complete Required PASRR Resident Review After 30-Day Exempted Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a required PASRR Resident Review Level 1 screening for a resident with a serious mental illness whose stay exceeded the 30‑day exempted hospital discharge period. The resident was initially admitted and later readmitted, with diagnoses including bipolar disorder, COPD, and hypertension. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, lower body dressing, and personal hygiene, as well as the use of antipsychotic medication. The resident’s H&P indicated the resident had capacity to understand and make decisions. Record review showed physician orders dated 11/18/2025 for quetiapine fumarate 100 mg by mouth at bedtime for bipolar disorder with aggressive angry outbursts, and a care plan dated 11/19/2025 addressing bipolar disorder with administration of antipsychotic medications as ordered. An initial psychiatric evaluation dated 11/21/2025 included a treatment plan to titrate medications according to symptoms, observe for deterioration in function, and provide emotional support for treatment compliance. A PASRR Level 1 screening dated 11/18/2025 indicated the resident tested positive for a serious mental illness. During interviews and concurrent record reviews, the MDS nurse confirmed that every resident has a PASRR Level 1 completed prior to admission and that a positive Level 1 typically triggers a more in‑depth Level 2 mental health evaluation. The PASRR Level 2 letter for this resident, dated 11/18/2025, documented that a Level 2 evaluation was not required due to an exempted hospital discharge, and specified that if the resident remained in the facility longer than 30 days, the facility must resubmit a new Level 1 screening as a Resident Review on the 31st day. The MDS nurse and DON both stated that the resident’s stay had exceeded 30 days and acknowledged that the facility was responsible for submitting a new Resident Review Level 1, which was not done. The facility’s admission policy and the DHCS PASRR Level 2 Screening Process webpage both indicated that for exempted hospital discharges, if the stay exceeds 30 days, the NF must submit a Resident Review Level 1 within the specified timeframe, which did not occur for this resident.
Failure to Care Plan for Resident Use of Bed Grab Bars
Penalty
Summary
The facility failed to develop a person-centered care plan with measurable objectives and interventions addressing one resident’s use of bed grab bars/side rails. The resident had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, and was documented as having severely impaired cognition on the MDS, as well as lacking capacity to understand and make decisions per the H&P. The resident was dependent on staff for toileting, bathing, and lower body dressing and had a responsible party identified. On observation, the resident was seen in bed with bilateral grab bars in place, which RN staff stated were used to aid in bed mobility and repositioning. Record review on the same date showed there were no physician orders for grab bars and no care plan addressing the use of grab bars or side rails from 10/26/2022 through the date of review. RN 1 acknowledged that, because the resident used grab bars for mobility and repositioning, a care plan should have been developed to reflect this use and to communicate to licensed nurses and CNAs the need to visually monitor the resident’s use of the grab bars, the condition of the equipment, and safety concerns such as entrapment. The DON similarly stated that a care plan should have been developed to indicate the reason for the grab bars and the interventions needed to minimize safety risks, including monitoring the resident’s position in bed and the working condition of the grab bars. The facility’s care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s needs, which was not implemented for this resident’s use of side rails.
Failure to Assess, Obtain Orders, and Secure Informed Consent Before Installing Bed Grab Bars
Penalty
Summary
The deficiency involves the facility’s failure to follow its own process and policy for bed safety and bed rail use before installing bilateral grab bars on the beds of two residents. For the first resident, who had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, the admission record showed a responsible party, and the MDS dated 11/2/2025 indicated severely impaired cognition with dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/9/2025 documented that this resident did not have the capacity to understand and make decisions. Despite this, during observations on 1/20/2026, the resident was seen lying in bed with bilateral grab bars in place, which RN 1 stated were used to aid in bed mobility and repositioning. During concurrent record review for the first resident, the Side Rail Utilization Assessment dated 11/2/2025 indicated that the resident did not have side rails currently in use or requested, even though grab bars were present on the bed. RN 1 stated she did not know when the grab bars were installed and acknowledged that an accurate side rail utilization assessment should have been completed to ensure the resident was safe and able to use the grab bars. Review of the active physician orders on 1/20/2026 showed no order for bilateral grab bars. RN 1 stated that an order was necessary to inform the physician of the need for grab bars and to allow the physician to determine whether installing them was safe, and that grab bars had the potential to be used as a restraint. Review of the electronic health record on 1/20/2026 showed no documentation that informed consent had been obtained from the responsible party for the use of grab bars, and RN 1 confirmed there was no documentation of informed consent. For the second resident, the admission record showed initial admission and readmission dates, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, lack of coordination, and weakness. The MDS indicated moderately impaired cognition and dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/25/2025 documented that this resident did not have the capacity to understand and make decisions and identified a surrogate decision-maker. On 1/20/2026, the resident was observed lying in bed with bilateral grab bars, which RN 1 stated were used to aid in repositioning. However, the Side Rail Utilization Assessment dated 1/14/2026 indicated that the resident did not have side rails currently in use or requested, and RN 1 did not know when the grab bars were installed. Review of active orders on 1/20/2026 showed no order for bilateral grab bars, and RN 1 confirmed there was no order for their use. The electronic health record on 1/20/2026 contained no indication that informed consent for grab bar use had been obtained or verified from the resident or surrogate decision-maker, which RN 1 acknowledged. In an interview, the DON stated that, prior to installing side rails on the beds of these residents, the facility was supposed to obtain a physician’s order, conduct a side rail utilization assessment, and verify that informed consent had been obtained. The DON explained that the physician’s order was necessary to ensure the physician agreed that installing side rails was appropriate and safe, that the side rail utilization assessment was needed to show other interventions attempted before using side rails, and that verifying informed consent ensured residents and their representatives were aware of safety risks associated with side rails. Review of the facility’s undated policy and procedure titled “Bed Safety and Bed Rails” showed that consideration was to be given to resident safety, medical conditions, comfort, freedom of movement, and input from the resident and family, and that bed frames, mattresses, and bed rails were to be checked for compatibility and size. The policy also specified that residents at higher risk for injury, including bed entrapment, required additional safety measures and that a resident assessment to determine risk of entrapment should include factors such as medical diagnoses, size and weight, sleep habits, medications, acute interventions, underlying conditions, delirium, toileting ability, cognition, communication, mobility, and fall risk. The policy further required that, before using bed rails for any reason, staff inform the resident or representative about benefits and potential hazards and obtain informed consent, including information on assessed medical needs, risks and mitigation, alternatives attempted and their failure, and alternatives considered but not attempted and the reasons.
Failure to Honor Resident’s Request to Withhold Medical Information From Family Contact
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s medical information by notifying a family member about the resident’s change in condition after the resident had clearly withdrawn consent for such disclosures. The resident, who had intact cognition and was documented as self-responsible with capacity to understand and make decisions, had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease. His admission record listed a family member as his first emergency contact. On 12/24/2025, the resident told an RN that he no longer wanted this family member to be informed about his care because she lived far away, could not visit, and he did not want her to worry. This request was documented in a progress note. The resident later reported feeling frustrated and distrustful of the facility because his request for privacy was not honored. Despite the documented request and the resident’s capacity for decision-making, a Change in Condition Evaluation dated 1/4/2026 showed that the same family member was notified when the resident developed new nasal drip, congestion, and cough. During interviews, the RN acknowledged that the family member should not have been notified and that the resident’s right to privacy and autonomy should have been honored. The DON confirmed that the resident had capacity, was self-responsible, did not want the family member informed of his care, and that the facility did not obtain or act upon the resident’s wishes, including not removing the family member from the face sheet as emergency contact. Facility policies on Resident Rights and Confidentiality of Information and Personal Privacy stated that residents have a right to privacy and confidentiality and that the facility would strive to protect residents’ privacy regarding medical treatment and personal care, but these were not followed in this case.
Improper Linen Use on Low Air Loss Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow established guidelines for linen use on a low air loss mattress (LALM) for a resident at high risk for pressure injuries and with an existing Stage 4 pressure injury. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent on staff for all ADLs, including hygiene and positioning. Clinical documentation showed the resident was at high risk for pressure injuries per the Braden Scale and had a Stage 4 pressure injury on the left trochanter. Provider orders directed the use of a P.R.O. Plus LALM for wound management, and the facility’s educational materials and staff statements indicated that only a thin sheet and a disposable pad should be used under residents on a LALM to avoid interfering with pressure redistribution. During observations in the resident’s room, surveyors noted that multiple layers of linens and pads were placed between the resident and the LALM, including a thin white sheet, a folded white sheet, a green pad, and a disposable pad at one time, and later a thin sheet, a folded sheet, and a disposable pad. A CNA acknowledged that only a thin sheet and disposable pad were supposed to be used and admitted placing an extra green pad earlier to assist with repositioning during wound treatment and leaving a folded sheet under the disposable pad to make it easier to pull the resident up in bed, despite knowing this was not correct. The treatment nurse and DON confirmed that additional linen layers under a resident on a LALM reduced the mattress’s effectiveness in offloading pressure and that staff had been educated to minimize linen layers. The facility’s user manual for the P.R.O. Plus support surface allowed for specific items such as a draw or slide sheet and an incontinence barrier pad, but the observed practice exceeded these guidelines, leading to the cited deficiency.
Failure to Follow Two-Person Assist and Side Rail Orders Resulting in Bed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were provided as ordered. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left side, hypertension, and aphasia, and was documented as severely cognitively impaired. The resident’s MDS dated 12/25/2025 indicated dependence on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The History and Physical dated 10/14/2025 stated the resident did not have the capacity to understand and make decisions, and a Fall Risk Assessment dated 12/25/2025 identified the resident as at risk for falls. The resident’s care plan for Activities of Daily Living Self-Care Deficit, initiated 10/13/2025, indicated the resident required two staff participation to reposition and turn in bed. A document titled Roll Left and Right Task, dated 12/26/2025 at 8:10 p.m., defined the resident as dependent for rolling, meaning the helper did all the effort or that two or more helpers were required. The DON and RN 1 both stated the resident required a two-person assist in bed mobility and repositioning because the resident was unable to hold herself up or keep herself from rolling over the edge of the bed when on her side. The facility’s Repositioning policy required staff to check the care plan, assignment sheet, or communication system to determine the resident’s specific positioning needs, including the number of staff required. Despite these documented needs and orders, on 12/26/2025 at approximately 9 p.m., CNA 4 provided incontinence care and repositioned the resident onto her right side alone, without a second staff member and without side rails in place. During the brief change, the resident began to shift and slide, causing the upper portion of her body to roll toward the floor, and CNA 4 assisted the resident to the floor in a controlled manner. CNA 4 stated she had previously repositioned and changed the resident’s diaper alone without issues, did not check the Kardex for the required level of assistance, and acknowledged the resident had no side rails on the bed. Review of the resident’s orders dated 10/14/2025 showed an order to apply bilateral half side rails to enhance bed mobility and repositioning, which were not in place at the time of the incident. The DON stated that precautions were not in place to safely reposition the resident and that the fall could have been prevented if a second person had been present and the ordered side rails had been installed.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the California Department of Public Health (CDPH) within the required timeframe. A resident with severe cognitive impairment, quadriplegia, and total dependence on staff for activities of daily living was re-admitted to the facility and later alleged to his responsible party that he had been hit by an unidentified male CNA. This allegation was communicated to the facility's Interdisciplinary Team during a meeting, and both the Director of Nursing (DON) and the Administrator acknowledged awareness of the allegation. Despite facility policy and federal requirements mandating that all allegations of abuse be reported within two hours, the DON and Administrator confirmed that the incident was not reported to the State Agency. The facility's own policies, reviewed during the investigation, also specified the need for timely reporting of abuse allegations. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with severe cognitive impairment, quadriplegia, and multiple complex medical needs, including a tracheostomy and gastrostomy. The resident, who was dependent on staff for all activities of daily living and mobility, was reported by his responsible party to have alleged being hit by an unidentified male CNA. This allegation was communicated during an Interdisciplinary Team meeting, and both the Director of Nursing and the Administrator acknowledged awareness of the report. Despite the facility's policies requiring thorough and timely investigation of all abuse allegations, no investigation was initiated into the reported incident. Both the DON and the Administrator confirmed that the allegation met the criteria for physical abuse and should have been investigated, regardless of the resident's or responsible party's ability to provide specific details about the perpetrator or timing. The lack of investigation was contrary to the facility's own policies and federal requirements.
Failure to Perform Timely Neurological Assessments After Alleged Head Injury
Penalty
Summary
Registered Nurse (RN) 1 did not perform neurological assessments (neuro-checks) at the required frequency and intervals for a resident who was allegedly struck on the head by a male Certified Nursing Assistant (CNA). The resident, who had severe cognitive impairment, quadriplegia, a tracheostomy, and a gastrostomy, was dependent on staff for all activities of daily living and mobility. Following the alleged incident, neuro-checks were ordered to be performed every 30 minutes, then hourly, as documented in the resident's record. However, the neuro-checks were not conducted at the scheduled times, with some checks being significantly delayed and others performed in rapid succession, not adhering to the required intervals. The Director of Nursing (DON) confirmed that the neuro-checks were not performed according to the ordered schedule and emphasized the importance of timely assessments to identify any changes or complications. The facility's policy and procedure for neurological assessments required staff to perform neuro-checks at the frequency ordered, but this was not followed in this case. The failure to adhere to the neuro-check schedule was documented in the resident's records and acknowledged by the DON during the investigation.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for a resident diagnosed with dementia, epilepsy, and generalized anxiety disorder. The resident was admitted with fluctuating mental capacity and required maximal assistance with activities of daily living, including dressing, toileting, personal hygiene, transfers, and bed mobility. Documentation reviewed included the resident's admission record, history and physical, Minimum Data Set, and psychiatric notes, all of which indicated significant cognitive and functional impairments, such as impaired judgment, concentration, and attention span, as well as a blunt or constricted affect. Interviews with nursing staff confirmed that no care plan addressing the resident's dementia had been created. Both an LVN and an RN acknowledged the importance of having an individualized care plan to guide staff in providing appropriate interventions and care for the resident. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not implemented for the resident in question.
Failure to Develop and Implement Resident-Centered Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who had physician orders for fluid restriction. The resident was admitted with a history of edema, chronic heart failure, and chronic kidney disease, and was able to make medical decisions. Physician orders were documented for fluid restriction, initially set at 1.5 liters per day and later reduced to 1 liter per day, with specific instructions for dietary intake and the use of a condom catheter for intake and output monitoring. Despite these orders and the resident's changing clinical condition—including peripheral edema, abnormal lung sounds, weight gain, vesicles on the lower legs, and later respiratory distress—the facility did not create or update a care plan to address the fluid restriction or the use of the condom catheter. Multiple record reviews and staff interviews confirmed that no care plan was developed or revised to reflect the resident's needs or the physician's orders, even as the resident's condition worsened. The facility's own policy required person-centered care plans with measurable objectives and timetables to meet each resident's needs, and for care plans to be updated as conditions changed. However, the care plans for this resident were found to be non-existent or not specific and resident-centered, failing to address the physician-ordered interventions and the resident's evolving symptoms.
Failure to Prevent Allergen Exposure Due to Inadequate Tray Card Identification and Verification
Penalty
Summary
The facility failed to follow established procedures for accommodating a resident's documented food allergies, resulting in the resident being served fish despite a known seafood allergy. The resident, who had diagnoses including dysphagia and a gastrostomy, was on a regular, no added salt, pureed diet with specific restrictions against white bread, milk, citrus, cheese, caffeine, and seafood. The resident's tray card, which should have clearly indicated these allergies, displayed the seafood allergy in small letters and not in pen, making it less noticeable to dietary staff. As a result, the kitchen assistant did not see the allergy and served the resident pureed fish. The resident consumed the fish, believing it to be chicken, and subsequently experienced an allergic reaction, including itching and numbness, requiring administration of Benadryl. Interviews with staff revealed lapses in the tray verification process. The dietary supervisor acknowledged the error and noted the allergy was not prominently marked on the tray card. The kitchen assistant confirmed the allergy was not easily visible, and the licensed vocational nurse admitted to not checking the tray due to other duties. The director of nursing emphasized the importance of double-checking trays to prevent such incidents. Facility policies required tray cards to list allergies and for staff to check trays for accuracy, but these procedures were not adequately followed, leading to the resident receiving an allergen-containing meal.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control measures for two of four sampled residents by not ensuring that staff wore appropriate personal protective equipment (PPE) and that required signage was posted. Specifically, a Licensed Vocational Nurse (LVN) and a Restorative Nursing Assistant (RNA) entered the room of a resident on Enhanced Barrier Precautions (EBP) without donning isolation gowns and proceeded to perform a wound dressing change. The resident had a stage 4 pressure ulcer, quadriplegia, and moderate cognitive impairment, and was dependent on staff for activities of daily living. Physician orders indicated the resident was to be on EBP due to open wounds, and the facility's policy required gown and glove use during high-contact care activities such as wound care. A similar failure was observed with another resident, where no EBP signage or isolation cart was present at the room entrance, and the same staff did not wear isolation gowns while performing a wound dressing change. This resident had osteomyelitis, hemiplegia, hemiparesis, diabetes mellitus, and severe cognitive impairment, and was also dependent on staff for daily care. Physician orders required daily wound care for a diabetic ulcer. Both staff members acknowledged during interviews that they forgot to use gowns and were aware of the need to wear PPE for residents on EBP. The Director of Nursing confirmed that EBP precautions, including gown use, should be followed for residents with wounds.
Failure to Supervise Medication Administration and Assess for Self-Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to supervise the medication administration for a resident who had not been assessed by the Interdisciplinary Care Team (IDT) for self-administration of medications. The resident, who had diagnoses including osteoarthritis, hypertensive urgency, and diabetes mellitus, was observed holding a cup with multiple medications at her bedside without a licensed nurse present. The LVN stated that the medications were left with the resident because she preferred to take them on her own, despite the absence of an IDT assessment or a physician's order permitting self-administration. Review of the resident's records showed that she required supervision or assistance for activities of daily living, such as eating and oral hygiene, and had no cognitive impairment. The medication orders included several drugs for blood pressure, diabetes, and other conditions, with specific administration times. The medications were scheduled for administration at a set time, but the LVN left them unattended at the resident's bedside, and the resident was not supervised during the process. Interviews with facility staff, including a CNA, RN, and the Director of Nursing (DON), confirmed that medications should not be left unattended and that an IDT assessment is required before a resident can self-administer medications. The facility's policy also requires an IDT evaluation to determine if self-administration is safe and appropriate. In this case, the required assessment and care planning had not been completed prior to the incident, and the medications were left with the resident without proper authorization or supervision.
Failure to Notify Physician of Sustained Abnormal Vital Signs
Penalty
Summary
The facility failed to assess and notify a resident's medical doctor when the resident exhibited sustained tachycardia and tachypnea. The resident, who had a history of chronic respiratory failure, tracheostomy dependence, pneumonia, and sepsis, was admitted with severely impaired decision-making capacity. On the day of the incident, the resident's respiratory rate was consistently above 30 breaths per minute and heart rate above 100 beats per minute for several hours, as documented in the flowsheets. Despite these abnormal vital signs, there was no immediate assessment or notification to the medical doctor. Nursing staff, including an LVN and an RN, were aware of the elevated vital signs but did not notify the physician until several hours after the onset. The RN acknowledged being too busy to address the situation promptly, and the LVN did not call the physician earlier. The facility's policies required immediate assessment and physician notification in the event of abnormal vital signs, but these protocols were not followed. As a result of the delayed response, the resident's condition was not managed in a timely manner, and the resident was eventually transferred to a general acute care hospital for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the abnormal vital signs should have prompted earlier physician notification and intervention, in accordance with facility policy.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of bilateral femur fractures, morbid obesity, contractures, functional quadriplegia, and cognitive impairment, the care plan and assessments indicated total dependence on staff for bed mobility and toileting hygiene, requiring two-person assistance. Despite this, a CNA performed perineal care and repositioning alone, without a second staff member. During this process, the resident was turned to the side and subsequently fell from the bed, resulting in bilateral femur fractures, hypovolemic shock, and the need for surgical intervention and blood transfusions. Multiple staff interviews and record reviews confirmed that the resident's care plan and assessments consistently documented the need for two-person assistance, and that the use of an air mattress increased instability, further necessitating additional support during care. Another resident, with diagnoses including generalized muscle weakness, reduced mobility, osteoporosis, and moderately impaired cognition, was identified as high risk for falls and had a care plan specifying that the call light should be within reach and fall mats should be present on both sides of the bed. Observations over several days revealed that the call light was not within the resident's reach and that fall mats were not present at the bedside, despite the resident's history of falls and care plan interventions. Staff interviews confirmed that fall mats had not been in place for at least a month, and that the absence of these interventions increased the risk of injury from falls. The facility's own policies required the environment to be free from accident hazards, for care plans to be comprehensive and person-centered, and for fall prevention interventions to be implemented based on individual risk factors. In both cases, the facility failed to follow its policies and the residents' care plans, resulting in a serious injury for one resident and increased risk for another.
Failure to Evaluate MDS Nurse Competency and Performance
Penalty
Summary
The facility failed to ensure that the Minimum Data Set Nurse (MDSN) demonstrated the required competencies for her position and did not conduct annual evaluations of her ability to accurately perform MDS assessments. Interviews with the Assistant Director of Nursing (ADON) and the MDS Nurse Consultant (MDSC) revealed that while the MDSN had access to the Resident Assessment Instruction (RAI) manual and was expected to follow it, there were no routine or annual performance evaluations in place to assess her competency in conducting MDS assessments. The MDSC stated that although she audited random MDS assessments monthly, this did not involve direct observation of the MDSN performing the assessments. A review of the MDSN's employee record indicated that her responsibilities included conducting resident assessments and ensuring accurate documentation of residents' health and wellness problems. The facility's policy required annual performance evaluations for all employees, but the Administrator confirmed that no such evaluation had been conducted for the MDSN. This lack of competency evaluation and oversight placed all residents at risk of receiving inaccurate MDS assessments, which could negatively impact their care plans.
Failure to Implement Infection Control Measures and Equipment Maintenance
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for five residents, as evidenced by multiple observations and record reviews. For two residents with enhanced barrier precautions (EBP) orders due to the presence of indwelling medical devices (a gastrostomy tube and a urinary catheter), there was no EBP signage or indicators posted outside their rooms, and no personal protective equipment (PPE) was available. The facility's policy required such signage and PPE to alert staff to the need for EBP, but these were not in place, as confirmed by the Infection Preventionist Nurse. For another resident, oxygen tubing, nebulizer, and respiratory setup bag were not changed according to the facility's policy, with equipment observed to be dated several weeks prior. Similarly, a different resident's oxygen humidifier was not changed as ordered by the physician, with the device observed to be in use well past the scheduled change date. These lapses were confirmed by staff interviews and review of facility policies, which required weekly changes of respiratory equipment to prevent infection. Additionally, a resident's suction tubing and suction filter were found lying on the floor, contrary to infection control standards and facility policy. Staff interviews confirmed that respiratory equipment should not be on the floor and should be replaced if contaminated. The facility's own policies and staff statements indicated that these practices were not followed, placing residents at risk for infection due to improper handling and maintenance of respiratory equipment.
Failure to Label and Return Resident's Personal Belongings
Penalty
Summary
A deficiency occurred when the facility failed to label the personal belongings of a resident who was admitted with schizophrenia and dementia, resulting in severe cognitive impairment and a need for partial to moderate staff assistance. The resident's family member brought in a blanket for her comfort, which was documented on the admission inventory list. However, after the blanket was laundered by the facility, it was not returned to the resident. The inventory list at discharge did not indicate that the blanket was returned, and the item was later found in outdoor storage by the Social Services Director (SSD). The SSD confirmed that the blanket was not labeled with the resident's name or any other identifier, which led to confusion among laundry staff regarding its ownership. The facility's policy required all personal belongings to be labeled to ensure they could be returned to the correct resident if misplaced. The lack of labeling resulted in the blanket being stored rather than returned to the resident, contrary to the facility's policy of providing a homelike environment and supporting residents' use of personal belongings.
Failure to Ensure Call Light Accessibility and Assistance with Adaptive Devices
Penalty
Summary
Staff failed to accommodate the needs and preferences of two residents by not ensuring their call lights were within functional reach and by not assisting one resident with her prescribed glasses. For one resident with a history of stroke, hemiplegia, and quadriplegia, the call light was placed on the side of the bed corresponding to his paralyzed hand, making it inaccessible. Despite care plan instructions to anticipate and meet his needs by ensuring the call light was within reach, the resident reported being unable to call for assistance due to the placement of the device. Staff interviews confirmed awareness of the resident's inability to use his right hand and the importance of call light accessibility. Another resident, with major depressive disorder, anxiety, and severely impaired cognition, was observed with a pad call light clipped to her chest, which she was unable to activate due to hand weakness and stiffness. Staff acknowledged that the call light placement was not functional and that the resident often relied on her roommate or yelling for help. After repositioning the call light to her abdomen, the resident was able to use it with her elbow. Staff interviews further confirmed the need for resident-specific assessment of call light placement to ensure accessibility. Additionally, the same resident required bifocal glasses for vision improvement, as prescribed by an eye doctor. Although the glasses were provided, the resident was unable to put them on independently due to limited hand mobility and reported that staff did not assist her when requested. The glasses remained unused in her bedside dresser until a staff member assisted her, at which point she expressed improved vision and a desire to wear them consistently. Staff interviews confirmed a lack of awareness regarding the resident's need for glasses and the importance of assisting residents with adaptive devices when necessary.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for four residents were completed and documented accurately, resulting in the transmission of inaccurate data to CMS regarding their health status. For one resident with major depressive disorder and anxiety, the MDS inaccurately indicated severely impaired cognition and failed to document the need for glasses, despite optometry records and interviews confirming the resident required bifocal glasses for vision. The MDS nurse assessed vision adequacy based on the resident's ability to wave in the hallway, without following the Resident Assessment Instrument (RAI) manual's guidance to assess close vision and use of corrective lenses. Interviews with facility leadership confirmed that the assessment was not conducted according to protocol, and the MDS did not reflect the resident's actual needs. Another resident with lack of coordination, muscle weakness, and failure to thrive was assessed in the MDS as having no upper or lower extremity impairments, despite physician orders for passive range of motion and physical therapy records indicating the resident could not perform active range of motion in any extremity. The Director of Rehabilitation and MDS nurse both acknowledged that the MDS was inaccurate and did not reflect the resident's true functional limitations. Direct observation confirmed the resident was unable to move any extremities or follow commands, further supporting the inaccuracy of the MDS documentation. A third resident with diabetes, congestive heart failure, and muscle weakness was documented in the MDS as having intact cognitive skills and being dependent for ADLs, but the oral/dental status was coded incorrectly, failing to reflect the resident's lack of natural teeth and broken dentures. The MDS nurse confirmed the error and acknowledged the importance of accurate MDS coding for care planning. A fourth resident with multiple fractures, morbid obesity, contractures, and functional quadriplegia was assessed in the MDS as requiring substantial or maximal assistance for bed mobility, but CNA documentation and therapy records indicated total dependence. The MDS nurse did not observe the resident or document interviews with staff, resulting in an inaccurate assessment. Facility policies required comprehensive assessments using direct observation and communication with staff, but these procedures were not followed.
Failure to Complete Required Level II PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a required Level II PASRR (Preadmission Screening and Resident Review) evaluation was completed for a resident with multiple mental health diagnoses, including schizophrenia, delusional disorder, bipolar disorder, and depression. The resident's records indicated intact cognitive skills and the need for assistance with daily activities. A Level I PASRR screening identified the need for a Level II evaluation to determine eligibility for specialized mental health services, but there was no evidence that this evaluation was completed or followed up on. Interviews with facility staff revealed a lack of knowledge and responsibility regarding the PASRR process. The Social Services Director stated she was not responsible for PASRR follow-up and was unfamiliar with the process, while the MDS nurse also indicated a lack of understanding and that the facility did not have a process in place for Level II PASRR evaluations. The Director of Nursing confirmed that there was no policy or procedure for PASRRs, and that the absence of follow-up could delay necessary mental health treatment for the resident.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for seven residents, resulting in unmet needs and lack of required interventions. For one resident with a history of falls and impaired mobility, the call light was not within reach and fall mats were not placed at the bedside on multiple occasions, despite care plan directives and a recent fall with injury. Staff interviews confirmed the absence of fall mats and the inability of the resident to access the call light, contrary to the documented care plan interventions. Two residents receiving insulin for diabetes did not have care plans addressing their insulin use, including necessary monitoring and interventions. Staff interviews confirmed the absence of these care plans, and it was acknowledged that such plans are necessary to guide staff in monitoring blood sugar, food intake, and potential side effects. Similarly, another resident who required corrective lenses did not have a care plan for their use, and staff were unaware of the need to assist the resident with wearing glasses, which were found unused in the resident's room. Additional deficiencies included the lack of care plans for seizure medications for one resident, a blood thinner for another, and missing teeth for a further resident, despite these conditions being documented in medical records and requiring specific interventions. One resident using a self-releasing wheelchair seat belt for safety also did not have an active care plan addressing its use. Staff interviews and record reviews consistently revealed that these omissions left staff without guidance on necessary interventions, monitoring, and support for these residents' specific needs.
Failure to Maintain Resident Nail Hygiene and Grooming
Penalty
Summary
The facility failed to maintain proper grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. One resident was observed with long fingernails and a brown substance underneath, and reported that no one had cut or cleaned his nails. This resident had diagnoses including dementia and major depressive disorder, with severely impaired cognitive skills and required moderate assistance for ADLs. The care plan for this resident specified that fingernails should be cleaned daily and trimmed as necessary, but this was not done. A CNA confirmed that the resident's fingernails were long and dirty, and acknowledged that CNAs were responsible for daily nail care. Another resident was observed with long toenails and a black substance underneath and around the toenails. This resident also had dementia and major depression, with severely impaired cognitive skills and required moderate assistance for ADLs. The care plan indicated daily cleaning and trimming of nails, which was not provided. The CNA and the Director of Staff Development both confirmed that nail care should be performed daily and that the residents' nails should have been addressed. Facility policies also required daily cleaning and regular trimming of nails for residents unable to perform self-care, but these were not followed for the two residents.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency was identified when a resident at high risk for pressure ulcers was observed lying on a low air loss mattress (LALM) that was not set according to the resident's weight. The mattress was set to a weight higher than the resident's actual weight of 293 lbs, as indicated on the control panel and confirmed by staff. Both a Licensed Vocational Nurse and a Treatment Nurse acknowledged that the mattress setting was incorrect and that the harder surface resulting from the higher setting was not appropriate for the resident's skin integrity needs. The facility's policy and the manufacturer's guidelines both require that the LALM be adjusted based on the resident's weight. The resident involved had multiple diagnoses, including morbid obesity, acute respiratory failure with hypoxia, congestive heart failure, anemia, and cirrhosis of the liver. The resident was bedbound, had severely impaired cognition, and was dependent on staff for all activities of daily living. The Braden Scale assessment indicated a high risk for pressure ulcer development. Staff interviews confirmed that all licensed nurses were responsible for checking the LALM settings every day and every shift, but this was not done, resulting in the resident being exposed to an improperly set support surface.
Failure to Notify Rehabilitation Team of Resident's New Contracture
Penalty
Summary
The facility failed to ensure that the Director of Rehabilitation (DOR) or the assigned Licensed Vocational Nurse (LVN) were notified of the development of a right-hand contracture in a resident with significant neurological and physical impairments. The resident, who had a history of cerebral infarction, hemiplegia, aphasia, muscle weakness, and was dependent on staff for activities of daily living and bed mobility, was found to have developed a contracture in the right hand. Review of records showed that the resident's right upper extremities were previously within functional limits, but an occupational therapy evaluation later documented impaired range of motion in the right hand and fingers. There was no documentation in the Certified Nursing Assistant (CNA) Stop and Watch Forms indicating that the change in the resident's condition was reported as required. Interviews with staff revealed that the normal process for reporting a change in condition involved completing a Stop and Watch form and notifying the LVN or DOR. The restorative nurse aide (RNA) who noticed the contracture did not complete the required form, although she recalled verbally notifying the Rehabilitation Department. The DOR confirmed not being made aware of the decline in range of motion, and the occupational therapist stated that timely notification would have led to prompt intervention, such as hand splinting. Facility policy and the RNA job description both required immediate reporting of changes in residents' conditions to supervisors, which was not followed in this case.
Failure to Assess and Change Midline Catheter Dressings as Required
Penalty
Summary
The facility failed to ensure proper assessment and care of midline catheter insertion sites for two residents receiving intravenous antibiotics. For one resident with a history of sepsis, peritonitis, and hypertension, the midline dressing was observed to be dated well beyond the recommended seven-day interval, and nursing staff confirmed that the site was not assessed every shift nor was the dressing changed as required by facility policy. This resident was cognitively impaired and dependent on staff for all activities of daily living, and was receiving IV Meropenem for peritonitis. For another resident with diagnoses including sepsis, major depressive disorder, and hypertension, the midline dressing was found to be soiled, dislocated, and also not changed within the seven-day timeframe. The resident was totally dependent on staff for ADLs and was receiving IV Ertapenem for sepsis. Nursing staff acknowledged that they were responsible for daily assessments and timely dressing changes, but these were not performed according to policy. Facility policy required site care and dressing changes every seven days or sooner if the dressing became damp, loose, or visibly soiled, and for all assessments and changes to be documented in the medical record.
Failure to Provide Effective Pain Management and Accessible Call Light
Penalty
Summary
A deficiency was identified when staff failed to provide safe and appropriate pain management for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including generalized muscle weakness, abnormal gait, right shoulder pain, dorsalgia, major depressive disorder, and anxiety disorder, was totally dependent on staff for repositioning and unable to move herself in bed. Despite care plans indicating the need for frequent repositioning and immediate response to pain complaints, the resident reported being left in the same position for four to five hours, resulting in severe back pain. Observations confirmed that the resident remained in the same position for extended periods, and staff interviews acknowledged the importance of repositioning at least every two hours to prevent pain. Additionally, the resident's call light was not placed within effective reach, preventing her from independently requesting assistance. The call light was initially clipped to her chest, but due to hand weakness and stiffness, she was unable to activate it. The resident often relied on her roommate to call for help, and when alone, was unable to summon staff. Multiple staff members confirmed that the call light placement was not functional and that it should be adjusted to meet the resident's needs. When the call light was repositioned to her abdomen, the resident was able to activate it with her elbow, demonstrating the previous placement's inadequacy. Facility policies reviewed indicated that pain management should include non-pharmacological interventions such as repositioning, and that staff should ensure call lights are accessible to residents. Despite these policies, the resident's needs were not met, as evidenced by her inability to request help and prolonged periods without repositioning, leading to unmanaged pain.
Failure to Communicate New Antipsychotic and Initiate Psychiatric Consult for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that a resident with a history of dementia, anxiety, depressive disorder, and agitation received necessary behavioral health care and services. Upon readmission from a general acute care hospital, the resident was prescribed a new antipsychotic medication (Seroquel), but there was no adequate documentation indicating that the attending physician was made aware of this new prescription. The admission summary note did not specify which medications were started or discontinued, and interviews with nursing staff confirmed that the process for verifying and documenting new medications with the physician was not properly followed. Additionally, when the resident exhibited physically aggressive behaviors, including scratching and hitting staff, the physician ordered a psychiatric consult. However, the order for the psychiatric consult was not entered into the electronic medical record, and the process for obtaining the consult was not initiated. The licensed nurse responsible believed the order had already been placed previously and did not follow through with the required steps, resulting in the consult not being obtained. Facility policy required that all medication changes be communicated to the attending physician and that verbal or telephone orders be documented in the resident's medical record. The policies also required that residents exhibiting behavioral health symptoms receive appropriate services and support. The failures in communication, documentation, and follow-through on physician orders led to a delay in necessary behavioral health treatment and services for the resident.
Failure to Maintain Safe and Operable Resident Room Equipment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have two gaps around the window screen, which allowed flies and mosquitos to enter. The resident confirmed that insects were entering the room through these gaps. Additionally, the resident's bathroom had a toilet seat that was not anchored in place and was broken, causing the resident to feel scared while using it due to the risk of falling. The maintenance manager confirmed that the window screen was not the correct size, resulting in a seven-inch gap on both sides, and acknowledged that the broken toilet seat was a safety issue. The maintenance manager also stated he was not previously aware of these issues and that it was his responsibility to maintain resident rooms and equipment in a safe manner. The resident involved had a medical history including diabetes mellitus, hypertension, and muscle weakness, and required supervision or assistance for activities of daily living, including toileting. Facility policy and procedure required that buildings and equipment be maintained in a safe and operable manner, and that regular inspections of resident rooms for safety be performed. The failure to maintain the window screen and toilet seat in proper condition was contrary to these policies.
Failure to Supervise and Monitor Exit Doors Results in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and adequate supervision of a resident at risk for wandering and elopement. The resident, who had diagnoses including COPD, diabetes, hypertension, difficulty walking, and schizophrenia, was assessed as having moderately impaired cognition and a history of wandering behaviors. On the day of the incident, the resident activated the front exit door alarm, but staff did not report the event to the charge nurse or implement closer monitoring or supervision. Multiple staff members observed the resident near the exit door and heard the alarm but did not take further action or communicate the incident to nursing leadership. Following the activation of the front exit door alarm, the resident was not closely monitored, and staff did not ensure that the facility's exit doors were properly supervised or that alarms were functioning. The back exit door alarm was not activated, and there was no staff presence at the back exit door. Surveillance footage later confirmed that the resident exited through the back door and left the facility unsupervised. Staff interviews revealed a lack of communication and follow-through regarding the resident's whereabouts and the need for increased supervision after the initial alarm was triggered. Additionally, the resident was not educated on the risks of leaving the facility after the first elopement attempt, despite care plan interventions indicating that such education should occur. The facility's policies required staff to communicate and implement interventions for residents at risk of elopement, but these procedures were not followed. The combination of unreported alarm activation, lack of supervision, failure to monitor exit doors, and absence of resident education directly led to the resident's elopement from the facility.
Removal Plan
- Staff initiated a search of the inside and outside of the facility including streets and nearby areas in partnership with the local Police Department.
- Facility-wide search for Resident 1 initiated by Registered Nurse (RN) 1 and staff.
- Headcount completed by RN 1 after Resident 1 was found missing.
- The Administrator (ADM), Director of Nursing (DON), and Maintenance Supervisor (MS) were notified by RN 1 of Resident 1's elopement.
- In-service trainings were conducted for all staff on elopement policies, procedures, and risks by the Director of Staff and Development (DSD) and the DON.
- Certified Nursing Assistant (CNA) 1 and CNA 2 were counseled and retrained on reporting alarms and elopement supervision by the DON and DSD.
- In-services initiated by the DSD for all shifts.
- All residents were reassessed for elopement risk by the DON.
- Newly admitted resident identified as high-risk for elopement and care plans updated accordingly.
- All new/readmitted residents assessed for elopement risk by the Inter-Disciplinary Team (IDT) members and/or the DON.
- Comprehensive assessments of residents conducted by the Minimum Data Set (MDS) Coordinator.
- Residents' care plans updated to reflect elopement risk by the MDS Coordinator and/or the DON.
- Backdoor exit to be supervised, maintained and validated by the MS and manager of the day. The MS to maintain a log and to be audited by the ADM.
- Receptionist to communicate to the RN supervisor and/or the charge nurse when leaving. The RN and/or the charge nurse to activate the alarm system to ensure monitoring of the back door exit. RN supervisor to update the monitoring log kept at the nursing station.
- Ensure all exit doors are equipped with functioning alarms.
- The MS to maintain a log to ensure alarm functioning, to be audited by the ADM.
- Installed additional alarms where necessary.
- Maintain documentation of alarm functionality.
- Mandatory in-services by the DSD for all staff on elopement procedures and monitoring exit doors after alarms, proper resident supervision strategies, assessment and care planning updates for elopement risks, educating residents on elopement dangers, and policy and procedures for managing wandering risk.
- Elopement risk audits to be conducted by the Medical Records Supervisor (MRS).
- IDT meetings to review findings and ensure follow-ups.
- Implementation of an Elopement Performance Improvement Plan (PIP) under Quality Assessment and Assurance (QAA).
- Elopement drills conducted by the DSD.
- Reporting process established for elopement incidents.
- Findings presented at QAA meeting.
- Ongoing audits reported by the DON and the ADM and/or designee.
- The facility to sustain compliance through continuous monitoring and training.
Failure to Follow COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to implement proper infection control practices by not adhering to the posted Novel Respiratory Precautions (NRP) for COVID-19 isolation rooms. Observations revealed that staff members, including a Licensed Vocational Nurse (LVN) and a Restorative Nurse Assistant (RNA), entered COVID-19 isolation rooms without wearing the required personal protective equipment (PPE) such as isolation gowns and face shields. Despite the presence of isolation signs indicating the need for gowns, N-95 masks, and face shields or goggles, staff members did not consistently follow these precautions. Interviews with staff, including LVNs, RNAs, the Infection Preventionist (IP) nurse, and the Director of Nursing (DON), confirmed that the facility's policy required the use of PPE when entering rooms with suspected or confirmed COVID-19 cases. The staff acknowledged the importance of following the posted precautions to prevent the spread of infection. However, lapses in compliance were noted, as some staff members either forgot to wear certain PPE items or misunderstood the necessity of full PPE usage in COVID-19 exposed rooms.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the timely reporting of injuries of unknown source to the State Licensing/Certification Agency. This deficiency involved a resident who was admitted with multiple medical conditions, including respiratory failure, hepatic encephalopathy, and a coagulation defect. The resident, who was unable to communicate or understand verbal content, was found with multiple skin discolorations and bruising on various parts of the body, including the left cheek, chin, shoulders, thigh, and elbow. Despite these findings, the facility did not report these injuries to the State Agency within the required timeframe, attributing them instead to the resident's medical conditions. The facility's P&P clearly stated that injuries of unknown source should be reported immediately, within two hours if abuse is suspected, or within 24 hours if not. However, the staff failed to report the injuries, delaying the investigation by the State Agency. Interviews with the Registered Nurse and the Administrator revealed that the injuries were considered suspicious due to their extent and location, and should have been reported as per the facility's P&P. The failure to report these injuries as required placed the resident at risk for continuous abuse, as the cause of the injuries remained unexplained and uninvestigated.
Failure to Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to investigate injuries of unknown source for a resident who developed new, multiple skin discolorations and bruising on the left cheek and chin. The resident, who was admitted with diagnoses including respiratory failure with hypoxia, hepatic encephalopathy, and a coagulation defect, was unable to speak, rarely able to make their needs known, and was totally dependent on staff for activities of daily living. Despite these conditions, the facility did not conduct a thorough investigation into the cause of the resident's injuries, which were considered suspicious due to their extent and location. Interviews and record reviews revealed that the facility's staff, including a registered nurse and the administrator, acknowledged that the injuries should have been investigated as potential abuse was not ruled out. The facility's policy and procedure for investigating injuries and preventing abuse required that all injuries be investigated, especially those of unknown source. However, the administrator admitted that the injuries were not thoroughly investigated and were instead attributed to the resident's medical history, contrary to the facility's established guidelines.
Failure to Implement Care Plan Leads to Skin Damage
Penalty
Summary
The facility failed to provide appropriate treatment and care according to the comprehensive person-centered care plan for a resident, resulting in Moisture-Associated Skin Damage (MASD) to the sacrococcyx area and bilateral groin. The resident, who was admitted with acute respiratory failure and total bladder incontinence, was supposed to be checked regularly for incontinence and have their perineum washed, rinsed, and dried as needed. However, the care plan was not adequately implemented, leading to the development of MASD. Interviews and record reviews revealed that the resident's MASD was preventable, and the facility did not ensure the resident's diaper was not too tight or wet, nor did they check the resident more frequently after the initial MASD was identified. The Director of Nursing acknowledged that interventions should have included keeping the resident dry and changing them on time to prevent the spread of MASD to other areas, which was not done, resulting in the condition worsening to the bilateral groin area.
Improper Management of Gastric Tube Feeding
Penalty
Summary
The facility failed to ensure the safe administration of gastric tube feeding for a resident, leading to a potential risk of aspiration. During an observation, a Certified Nursing Assistant (CNA) was seen lowering the head of the bed while the resident's tube feeding pump was still running. This action was contrary to the physician's order, which required the head of the bed to be elevated to 30 to 45 degrees during feeding. The CNA acknowledged that the feeding pump was on and subsequently paused it, although CNAs are not authorized to operate the feeding pump as per facility policy. Further interviews revealed that the Licensed Vocational Nurse (LVN) confirmed that CNAs should not handle the feeding pump, as it is outside their scope of practice. The Director of Nursing reiterated that CNAs must notify a licensed nurse to pause and restart the feeding pump. The facility's policy on enteral tube feeding mandates that the resident's head of the bed should be elevated during feeding unless medically contraindicated. The failure to adhere to these protocols placed the resident at risk for complications such as aspiration and pneumonia.
Failure to Provide Adequate Assistance During Transfer
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Hoyer Lift to transfer the resident from the bed to a Geri-chair. This resulted in the resident falling and sustaining an acute fracture of the fifth cervical vertebra. The resident was subsequently transferred to a general acute care hospital for evaluation and treatment. The resident, who had diagnoses including quadriplegia, hypertension, anxiety, and major depressive disorder, was totally dependent on staff for transfers and activities of daily living, requiring a two-person assist for safe transfers. Despite this, CNA 1 attempted to transfer the resident alone using a Hoyer Lift, which led to the lift tipping over and the resident falling to the ground. The CNA admitted to rushing and not asking for assistance, acknowledging that the fall could have been avoided with proper help. Interviews with other staff members, including another CNA and the Director of Nursing, confirmed that the resident required a two-person assist for transfers. The facility's policies and procedures, as well as the manufacturer's user manual for the Hoyer Lift, also indicated the necessity of a two-person assist to ensure resident safety and prevent accidents. The failure to adhere to these guidelines directly contributed to the resident's fall and subsequent injury.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure a resident was free from neglect, resulting in a serious incident involving a mechanical lift. A Certified Nursing Assistant (CNA) did not follow the care plan that required a two-person assist when using a Hoyer Lift to transfer a resident with quadriplegia. The CNA attempted to transfer the resident alone, which led to the Hoyer Lift tipping over and the resident falling to the ground, causing a fracture in the C5 vertebra. The resident, who had a history of quadriplegia, hypertension, anxiety, and major depressive disorder, was totally dependent on staff for transfers and activities of daily living. The care plan specifically required a two-person assist for transfers using a Hoyer Lift. Despite this, the CNA proceeded with the transfer alone, citing a busy schedule and the unavailability of other staff as reasons for not seeking assistance. This decision resulted in the resident experiencing severe pain and requiring hospitalization for evaluation and treatment of the injuries sustained. Interviews with the CNA and the Director of Nursing confirmed that the CNA was aware of the requirement for a two-person assist but chose to proceed alone due to time constraints. The facility's policies emphasized the importance of treating residents with dignity and ensuring their safety, which includes adhering to care plans and preventing neglect. The incident was classified as neglect, as the CNA's actions directly led to physical harm and pain for the resident.
Failure to Provide Correct Therapeutic Diet
Penalty
Summary
The facility failed to provide a resident with the correct therapeutic diet as ordered by the physician. The resident, who was diagnosed with depression and dementia, was supposed to receive a minced and moist diet due to difficulties with chewing and swallowing. However, during an observation, the resident was served food that did not meet the required minced/moist consistency, including full-size pasta, slices of squash, and a regular bread roll. The resident's medical records, including the Minimum Data Set and progress notes, indicated severe cognitive impairment and a need for moderate assistance with eating. The dietary profile and nutrition assessment confirmed the resident's diet order as minced and moist. Despite this, the food served did not adhere to the prescribed diet, posing a risk of choking and other complications. Interviews with facility staff, including a CNA, a dietary aide, an LVN, and the DON, revealed a lack of adherence to the facility's policies and procedures regarding therapeutic diets. The dietary aide acknowledged that the served bread roll was inappropriate for the resident's diet, and the DON emphasized the importance of providing the correct diet to prevent health complications. The facility's policies required staff to inspect food trays and report any discrepancies, which was not followed in this instance.
Failure to Obtain Informed Consent for Increased Lorazepam Dosage
Penalty
Summary
The facility failed to obtain informed consent before administering an increased dosage of lorazepam, a psychotropic medication, to a resident. The resident, who was admitted with anxiety disorder and depression, had intact cognitive skills and the capacity to understand and make decisions. Despite this, the facility increased the resident's lorazepam dosage from 0.5 mg to 1 mg without obtaining informed consent, violating the resident's right to make an informed decision about their treatment. Interviews with facility staff, including Licensed Vocational Nurses and a Registered Nurse, confirmed that informed consent was not obtained for the increased dosage of lorazepam. The staff acknowledged that informed consent is necessary for any change in dosage of antipsychotic medications and that the medication should not have been administered without it. The facility's policies on resident rights and antipsychotic medication use also emphasize the importance of informed consent, which was not adhered to in this case.
Failure to Update Care Plan for Medication Change
Penalty
Summary
The report identifies a deficiency in the care planning process for a resident diagnosed with anxiety disorder and depression. The resident was admitted to the facility with a physician's order for Lorazepam 1 mg every 12 hours as needed for anxiety. However, the care plan, dated earlier, indicated a different dosage of Lorazepam 0.5 mg every 12 hours. This discrepancy between the physician's order and the care plan was not updated, which could lead to the resident not receiving the correct medication dosage. Interviews with nursing staff, including an LVN and an RN, revealed that the care plan should have been revised to reflect the updated medication order. Both nurses acknowledged the importance of updating care plans to ensure continuous and accurate care. The facility's policy on care plans, which mandates revisions when a resident's condition or treatment changes, was not followed in this instance, leading to the potential for medication errors and impacting the resident's well-being.
Failure to Answer Call Lights Promptly
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, which had the potential to negatively impact their health and psychosocial well-being. Resident 1, who was bedridden due to fractures, reported that it took staff at least 15 minutes to respond to her call light, and she was told to wait for assistance because staff were going on a break. This delay in response was a daily occurrence for all residents, according to Resident 1. Resident 2, who had respiratory failure and impaired vision, stated that staff were reluctant to answer call lights and often responded with an attitude. She expressed that staff questioned her need for help and sometimes yelled at her. Resident 2 felt neglected, especially at night when her call light was not answered, leading her to believe that in an emergency, no one would come to her aid. Resident 3, who required maximal assistance due to hemiplegia and respiratory failure, reported that her call light was often inaccessible and, when used, was not answered promptly. She experienced delays of up to two hours for diaper changes. Interviews with staff, including an LVN, CNA, DSD, and DON, revealed that the facility's policy required call lights to be answered within five minutes, but this was not being consistently followed, leading to delays in care and unmet resident needs.
Failure in Safe Oxygen Administration
Penalty
Summary
The facility failed to provide safe oxygen administration practices for a resident, identified as Resident 2, by not adhering to the physician's order of administering oxygen at 2 liters per minute (LPM). During an observation, it was noted that the oxygen was set at 3 LPM, contrary to the prescribed amount. Additionally, the nasal cannula tubing was not labeled, which is a requirement for infection control and to ensure proper tracking of equipment usage. Resident 2, who was admitted with diagnoses including respiratory failure with hypoxia and chronic pulmonary edema, was observed with the nasal cannula on the floor. The resident expressed concerns about the tubing being a tripping hazard and mentioned that staff did not replace the tubing after it had been on the floor. The resident also reported a lack of slack in the tubing, which contributed to the frequent contact with the floor. The tubing was observed to have white particles and was tangled under the oxygen compressor's wheels, with a wheelchair wheel on top of it. Interviews with staff, including an LVN and the Director of Nursing (DON), revealed a lack of knowledge regarding the facility's policy on oxygen administration and the specific orders for Resident 2. The LVN admitted to placing the nasal cannula back on the resident after it had been on the floor without replacing it. The DON emphasized the importance of following physician orders and labeling oxygen equipment to prevent infections. The facility's policy on oxygen administration, dated 10/2010, requires staff to verify doctor's orders and review the resident's care plan before administering oxygen.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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